Employers often provide employees with various benefits upon commencement of employment. These benefits typically include a prescription drug plan, which varies depending on the particular healthcare provider selected by the employer. The specific coverage offered to an employee may depend on several factors, such as, for example, the particular coverage program negotiated by the employer, the medical coverage desired by the employee, the number of tiers in the prescription drug plan, the co-pay amounts, the drug coverage rules, the prescription medication available to the employee, the preferred drug lists associated with the prescription drug plan, the usage of mail order for certain prescriptions, etc. Certain events may also affect an employer's prescription drug plan, such as the introduction of generic drugs, the introduction of a new drug, the introduction of new drug benefits, or a shift in a drug from prescription to over-the-counter. For example, effective Jan. 1, 2006, the United States government implemented the Medicare Part D Prescription Drug Benefit plan.
Regardless of the coverage, the healthcare provider will place certain restrictions and/or limitations on the prescription medication available to the employee. These restrictions determine whether the healthcare provider will cover the cost of a prescription claim in full or in part. For example, the healthcare provider may cover the cost of a prescription claim in full, if the employee is willing to substitute a generic form of the prescribed medication in place of the brand name drug. In another example, the healthcare provider may subsidize the cost of the prescription to different degrees depending on, for example, if the employee prefers to use a brand name form of the prescribed medication.
Healthcare providers can face difficulties in managing coverage plans depending on various factors. For example, a healthcare provider may render services to a number of employers, where each employer offers coverage to multiple patients (e.g., employees, their domestic partners, their spouses, their children, their dependents, etc.). The number of patients generally varies based on the size of the employer and availability of alternative coverage plans (e.g., alternative healthcare providers). In the case of a large employer with few alternative coverage plans, the healthcare provider may be responsible for managing benefits of a great deal of patients. This situation is further complicated if the healthcare provider extends coverage plans to additional large employers.
When healthcare providers receive claims, each claim must be reviewed to ensure that they are supported by the patient's coverage plan. In the case of filling prescriptions, immediate approval or denial is required while the pharmacist prepares the prescription. It can be difficult to quickly approve or deny the prescription if the patient's prescription plan includes a large number of restrictions. Further complications arise when the patient requires specialized medication. It is possible to mistakenly support the prescription claim through the coverage plan if a restriction is overlooked. It is also possible to mistakenly deny the prescription claim if a restriction is misinterpreted.
For example, when the Medicare Part D Prescription Drug Benefit was implemented in January 2006, pharmacies discovered a number of problems. In some cases, pharmacies attempting to fill prescriptions from these Medicare patients discovered that these patients were not yet enrolled or registered in the computer systems under their new drug prescription plan. In other cases, pharmacies found that it was difficult to determine whether the prescriptions requested by these patients were covered by the new prescription plan. As a result, Medicare patients were not receiving the medication they required in a timely manner, or pharmacies were providing small dosages of the medication to those in a life-or-death situation and hoping that the government or healthcare providers would reimburse them at a later time. In response, many states have declared a public health emergency, where the state would provide short-term aid to pharmacies to assist in getting these prescriptions filled.
Prior art methods do not effectively manage and/or administer prescription benefit plans as in the present invention. For example, U.S. Pat. No. 6,694,298, entitled “Computer implemented patient medication review system and process for the managed care, health care and/or pharmacy industry,” and assigned to the assignee of the present invention, relates to an interactive computer assisted method that reviews, and analyzes, one or more medications of a patient. The method includes the steps of pre-selecting patients to obtain a preliminary set of patients eligible for the method responsive to first predetermined criteria, and filtering the preliminary set of patients to identify and form a secondary set of patients having a greater likelihood of benefiting from the interactive computer assisted method. The method also includes the steps of enrolling a patient from the secondary set of patients, and communicating with the patient to obtain information to assist the user in determining whether therapy and/or medication issues are relevant. The method also includes the steps of preliminarily evaluating whether the therapy and medication issues are relevant responsive to the information, and communicating to a physician same. The method also includes the steps of determining whether the therapy and/or medication issues are relevant, and suggesting therapy changes, medication changes, or no changes for the patient. Accordingly, while this patent provides excellent review of patient medications, it is not directly related to managing and/or administrating a prescription benefit plan or program.
U.S. Pat. No. 6,697,783, entitled “Computer implemented medical integrated decision support system,” also assigned to the assignee of the present invention, relates to a software-based, integrated member decision support system that provides corporations, insurance carriers, health maintenance organizations, physicians, physician groups, or other clients to efficiently provide medical, pharmaceutical, and health benefit advice and information for an enrolled population. The system contains one or more databases which include member profiles, clinical information and guidelines, pharmaceutical information and guidelines, health benefit information, and optional additional information. A caller establishes communication with the system, which directs the caller to an operator who provides the caller with medical, pharmaceutical, and/or health benefit advice based on an inquiry from the caller and the information stored on the system. The system may automatically alert the caller or the operator of important medical or pharmaceutical information. At the conclusion of the call, the system or the system with the operator's input, may update the caller's member profile, request written materials, generate referrals, order prescriptions, or generate reports.
U.S. Pat. No. 5,845,255, entitled “Prescription Management System,” relates to a wirelessly deployable, electronic prescription creation system for physician use captures into a prescription a patient condition-objective of the prescribed treatment and provides for patient record assembly from source elements, with privacy controls for patient and doctor, adverse indication review and online access to comprehensive drug information including scientific literature. Extensions to novel multi-drug packages and dispensing devices, and a remote data retrieval architecture as well as onscreen physician-to-pharmacy and physician-to-physician e-mail are also provided.
U.S. Pat. No. 7,020,618, entitled “Method and System for Customer Service Process Management,” relates to a method and system for managing customer service processes for individual customers and populations of customers. A clinician creates or updates a draft care plan for a patient using generic or locally-adapted template metadata and tailors the draft care plan to the particular patient. The draft care plan includes a list of specific services (health care interventions) to be provided to the patient. The draft care plan can be routed to members of an inter-disciplinary team for input. Once finalized, workflow processes are instantiated for each intervention on the care plan. An itinerary is created for any required patient encounters, optimized using an algorithm that considers pre-existing process instances. A workflow automation server manages the execution of each workflow process instance, invoking resources according to workflow process specification metadata and workflow task type metadata. Care plans and encounter itineraries are automatically translated to a patient-understandable form and made available to patients online and via printed copy. Clinical practice and outcomes data are analyzed to identify opportunities for improvement of the metadata. The method and system also allows for the selection of a population of patients, the analysis of population data to identify opportunities for interventions (needed services), and the initiation of population interventions through batch updates to individual care plans.
U.S. patent application 2003/0225595 entitled “Prescription Management System,” also assigned to the assignee of the present invention, relates to a medical prescription order processing method for mail order pharmacy industry, and involves processing an order by executing actions necessary to progress the order from an initial queue to a final queue. An imaging and workflow method, system, and computer readable medium and user interface is provided for processing information efficiently for medical prescription orders. The system includes support for document scanning, automated rules-based order processing, statistical reporting, document generation and document storage and retrieval. The system takes advantage of imaging technology to assist the user in scanning information into the system and software modules to improve the processing of orders. The system also includes database tables that identify to application processing logic the types and sequences of actions to be implemented for orders.
U.S. patent application 2005/0060197 entitled “Computerized Prescription System for Gathering and Presenting Information Relating to Pharmaceuticals,” relates to professional data management systems useful in the production of product specification documents such as prescriptions, service or parts orders, insurance contracts and the like that require detailed product and history information from multiple extensive information sources, especially remote sources. More particularly, the system assists professionals perform their everyday work in specifying customized technical products. One embodiment relates to a computer-implemented prescription management system that assists physicians in prescribing and reviewing drugs.
Thus, none of the above patents directly deal with managing and/or administrating a prescription benefit plan or program. Accordingly, there exists a need for a prescription benefits management system that is effectively and efficiently managed, and that overcomes these and other deficiencies in prior art systems.